HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 252 RALEIGH TAVERN LANE 11/13/2025 Town of North Andover
L4 Commonwealth of Massachusetts
...............
City/Town of NORTH ANDOVER NOV 19 2025
System Pumping Record
Form 4
Health Department
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 252 RALEIGH TAVERN
---......................................
key to move your Address
cursor-do not NORTH ANDOVER MA 01845
usethe return .................. ............. .. ........................... .......... -.- -......................
key. Cityfrown State Zip Code
2. System Owner:
LAURA NARDONE
Name
... .........................
Address(if different from location)
. .........--------- ..........
cittyaown State Zip Code
Telephone Number
B. Pumping Record
11/13/25 1500
1. Date of Pumping 2. Quantity Pumped: Gallons
Date
3. Component: F-1 Cesspool(s) Z Septic Tank El Tight Tank El Grease Trap
R Other(describe): "I'll,. ...... .............
4. Effluent Tee Filter present? Ej Yes El No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
---------------------------- -----------------
6. System Pumped By:
JAY CURRIER H79406
Name-------------------------------------------- Vehicle License Number
J'S SEPTIC & DRAIN
-Company' -'---------
7. Location where contents were disposed:
GLSD ---—------
11/13/25
Sign e r Date
Sign
............ ...........
—-- --------
/agnat'6're of Receiving Facility(or attach facility receipt) Date
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